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APPLICATION FOR SANITATION PERMIT Permit No. ._l_.1. ... (complete in Duplicate) Date Issued ______/ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION = ti_ uze . T � .. ° - - ---------- -------------- Owner's Name _ ii 1. _ - --- -- -- ' Phone...................----------' 2Address - -+� `�---=----- . :. �' �R ----- Contractor's Name---------------------------- t--- - ---it/ f ---. Phone---------------------------------- Installation will serve: Residence Apartment House [❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .-.___ Number of bedrooms 5__ Number of baths 1____ Lot size _ f�_'X_�_ F Water Supply: Public system ❑ Community system ❑ Private ® Depth to Water Table �Z__. ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ ± Previous Application Made: Yes ❑ No [��New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well--2A--'N'Distance from foundation-/ _7Nr Iaterial____ -----------_?----------� �{] No. of compartments__-____ _______._TSize_ .x1f�__X__ __.___Liquid depth'______ ______________Capacity__Q��.._�-�________ Disposal Field: Distance from nearest well... Distance from foundafion__�,-�-., X.Distance to nearest lot line____-__-________ Number of links______ - ^ ----- --Length of each line-------Za__L�--------.Width of trench----_-1___-`? -,r�-------------- Type of filter material__s;�C-�__Depth of filter material-----/Fr" ------Total length_______Z/9.__ __________..______,_ Seepage Pit: Distance to nearest we€l-_____________________Distance from foundation----------.._-------Distance to nearest lot fine----------------- ❑ Number of pits----------------- ----Lining material---------------•-------Size: Diameter----------------------_.Depth--------------------------------- "V Cesspool: Distance from nearest well-------_---------Distance from foundation--------------------Lining material--------------------- ❑ Size: Diameter---------------------------------------Depth----------------------------------------------------Liquid Capacity----------------- ---------gals. Privy: Distance from nearest well---------------------------_---------------------Distance from nearest building___.__..._-----_-_-___-______.______._._. ❑ Distance to nearest lot lire-------------------------------------------------------------------------------------------------------------------------------------------\-- Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------------------------------------=---------------- -------------- ------------------------------------- ------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------=--•--------------- ---------------------------------------------- I hereby certify that I have prepared this application-and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed ` '. ----------- ---------------------r _______________(Owner and/or Contractor) i By:......••---------------------------------------------------------------------------------------------------------------------------(Title)----------------------------------- --------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). - - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------• ' DATE---__ f✓f � REVIEWEDBY------------------------------------------------------------------------------------------------------------------------- ----- DATE--------------------------------------------------- BUILDINGPERMIT ISSUED-------------------------------------------------------------------- --------------------------------- DATE------------------------------------------------------------ Alterations -------------------------------------------- Alteratios and/or recommendations_______________________ - -------------------------------•--------•-------------------------..-------•----•--------------------- ------- �° r - -----------------------------------------------------------------------------------------------•-------•--------------•-------------------••-------------------------•--------------------------------------------------••-- --------------------------------------------------------------------------- --------------------------- ------------------------ -------------•---------- ----------------------------•-------------------------------- FINAL INSPECTION BY:----------- ---------- Date � ` SAN JOAQUIN LOCAL, HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California Revise 1.57 EP,CO.